Summary

The new NHS Oversight Framework 2025/26 describes a consistent and transparent approach to assessing integrated care boards (ICBs) and NHS trusts and foundation trusts, ensuring public accountability for performance and providing a foundation for how NHS England works with systems and providers to support improvement. It has been developed with the engagement and contributions from the NHS leadership and staff, representative bodies and think tanks, including through two public consultations. They said that NHS England’s approach to oversight and performance improvement needs to be consistent and our interactions coherent.

This 1-year framework sets out how NHS England will assess providers and ICBs, alongside a range of agreed metrics, promoting improvement while helping us identify quickly where organisations need support.

The framework will be reviewed in 2026/27 to incorporate work to implement the ICB operating model and to take account of the ambitions and priorities in the 10 Year Health Plan.

The framework is supported by a focused set of national priorities, including those set out in the planning guidance for 2025/26, aiming to strengthen local autonomy. These are presented alongside wider contextual metrics that reflect medium-term goals in areas such as inequalities and outcomes. The contextual metrics do not constitute part of the score but will inform how NHS England responds to segmentation.

The NHS priorities and operational planning guidance 2025/26 made it clear that achieving a financial reset this year is a priority. The NHS must live within the budget it is allocated, reduce waste and increase productivity to deliver growth against demand. It set the expectation that every ICB and provider must deliver a balanced net system financial position in collaboration with its system partners. NHS England will identify organisations that are not performing and take quick action. Our approach to assessment will mean that  unless providers are delivering a surplus or breakeven position, their segmentation will be limited to no better than 3.

Our improvement approach will be based on the results of our assessment and tailored to the support providers in each delivery segment need. Discussions about performance will be led by colleagues at NHS England who are experienced in addressing delivery challenges, with a focus on offering informed evidence and practical guidance that is grounded in a deep understanding of the operational challenges faced.

Our assessment will be the starting point for how we work with organisations throughout the year and will help us determine how we can support them to improve. We will do this by considering an organisation’s segment score, as set out in this framework, and leadership capability.

The framework outlines the circumstances in which providers can obtain increased freedoms. It also describes how we will determine whether a provider’s performance falls below an acceptable standard and/or has governance concerns that may lead NHS England to use our regulatory powers to step in and secure improvement. NHS England’s approach to the use of enforcement powers is set out in the NHS enforcement guidance.

We will not be segmenting ICBs in 2025/6, as this will be a year of significant change for ICBs as they transform in line with the Model ICB Blueprint to focus on strategic commissioning and implement plans to meet the running cost reductions. Support for ICBs  this year will focus on the safe implementation of their plans. ICBs that are currently in the Recovery Support Programme will continue in this programme and will be assessed against their current improvement trajectory to agree a transition plan. This will be the equivalent to segment 5. 

We will report ICB performance against the full suite of oversight metrics, but we will not issue a comparative rating.  ICBs will still be assessed through a statutory annual assessment, which reviews how well each ICB is performing its statutory duties. Where there are performance or governance concerns, NHS England will step in and we may use our regulatory powers to secure improvement. We will introduce the segmentation approach for ICBs in 2026/27.

Performance assessment

Roles and responsibilities

We recognise that streamlining the NHS operating model will be an important step in laying the foundations for the delivery of the 10 Year Health Plan. We need a less duplicative, leaner and simpler way of working, where every part of the NHS is clear on its purpose, what it is accountable for and to whom. The clarified roles and responsibilities for ICBs, providers and NHS England are set out below.

Overview

NHS England will use the performance assessment process to measure delivery against an agreed set of metrics. This will determine the segment score for each provider and identify where improvement is required. NHS England’s improvement response will be based on the segmentation score alongside consideration of the organisation’s leadership and governance (provider capability) to ensure that it is tailored and nuanced, balancing performance improvement and management. We plan to finalise our approach to the assessment of provider capability and issue guidance during Q2. It is our intention is to align our approach with that of the Care Quality Commission (CQC).

Drawing on the 4 purposes of an ICS (improving population health and healthcare; tackling inequalities in outcomes, experience and access; enhancing productivity and value for money; and supporting social and economic development), the performance assessment process measures each provider’s delivery on key metrics across 6 domains, as set out in Table 1. Each domain has a range of appropriate metrics for each type of organisation (acute, mental health, community and ambulance trusts).

For this transitional year, a focused set of metrics, which reflect the 2025/26 NHS priorities and operational planning guidance, will contribute to the segment score for an organisation. While not scored and rated as part of our segmentation approach, we have identified a longer list of contextual metrics that sit largely in the areas of population health, primary prevention and health inequalities. The performance data on contextual metrics will be available for boards to consider, aligned with the Insightful Board approach (as described in the Insightful provider board guidance) and we will consider this in our oversight response. Annex A identifies those metrics that will be scored and those that are contextual.

Table 1: Scoring and non-scoring domains of the framework

Where providers are part of a provider collaborative or group model, they will be measured as a trust and not as a wider group. The effectiveness with which providers are collaborating and supporting system working will form part of the provider capability assessment.

Integrated care boards

For ICBs, a set of metrics and system considerations have been selected to reflect the NHS priorities and operational planning guidance, system performance and longer-term strategic priorities. However, ICBs will not be segmented this year, given the significant changes they are undertaking during this year. This means these metrics will not be scored to inform segmentation, but they will be reported as contextual information to be used in strategic planning and improvement conversations. Although ICBs will not be segmented, their leadership capability will be assessed through our annual assessment of ICBs, which reviews how well each ICB is performing its statutory duties.

Primary care providers

Primary care providers, primary care networks and other non-trust providers or partnerships, such as provider collaboratives, will not be allocated their own segments. However, we will continue to keep under review our arrangements for accountability of primary care providers as we move towards the planned shift to neighbourhood health.

Independent providers

For independent providers of NHS services, ICBs will be expected to continue to ensure quality and performance through contractual levers and escalate concerns to NHS England regions. We will continue to oversee and assure certain independent providers under the Independent Providers Risk Assessment Framework (IPRAF) and NHS-controlled providers under either the IPRAF or this framework.

Segmentation approach

Figure 1: Process for determining a segment

Step 1 – Organisational delivery score

Each provider will receive an individual organisational delivery score derived from its performance against the metrics listed in Annex A.

Each metric has an individual set of scoring rules and based on these, a provider will receive a score between 1 and 4 for each metric.

To calculate the overall organisational delivery score, the individual metric scores are averaged according to the number of metrics the organisation will be measured against. The scores are then benchmarked against those for the rest of the country and divided into 4. These quartiles are numbered 1 to 4 with the highest performance scoring quartile numbered 1 and these numbers become each organisation’s overall organisational delivery score.

Further detail on the scoring approach is given in the separate methodology manual. The specific scoring regime for each metric will be detailed in a separate technical document that we will publish when we release initial segments in July.

Step 2 – Financial override

As part of the scoring methodology an override relating to organisational, not system-wide, financial performance will be applied. The override means all organisations in deficit or in receipt of deficit support will be limited to an organisational delivery score of no greater than 3.

Step 3 – Segmentation

Based on the process described above, we will place every provider into a segment. This indicates its level of delivery from 1 (high performing) to 4 (low performing) and informs its support or intervention needs. Entry into segment 5 will be reserved for the most challenged organisations that require the most support to improve. See Table 2 for descriptions of the 5 segments.

Step 4 – Allocation to segment 5

To establish which providers will be allocated to segment 5, we will review the outputs of both segmentation and capability assessments. Those providers rated low for both performance and capability will be considered for entry into the Provider Improvement Programme (PIP), which replaces the Recovery Support Programme (RSP), and is the support for the most challenged providers. All providers in the PIP will be placed in segment 5. Providers already in the RSP will be placed in segment 5 when the initial segments for 2025/26 are published in July 2025. For providers currently undergoing a diagnostic as part of the planning process, the outcome of the diagnostic will inform their potential entry into the PIP and segment 5.

In exceptional circumstances, where NHS England has identified concerns about a provider’s capability such as failures of governance, it may be necessary, regardless of the provider’s existing segment, to review whether it should be placed in segment 5 and the PIP. This is to ensure it is allocated the appropriate support and intervention. This review will be agreed with the appropriate NHS England committee.

Finalisation of segments

Once NHS England has approved the final segmentation decision, this will be officially communicated to each organisation and published on NHS England’s website.

Segmentation data will be reviewed at least quarterly as part of a review meeting and segments may be updated at any time based on emerging information.

Table 2: Segment descriptions

Publication of data

To support transparency, NHS England will publish a dashboard to give the public access to the data that underpins segmentation.

Each provider’s domain scores, organisational delivery score and final segmentation will be shown alongside the individual metric scores used to calculate them. Although contextual metric results for providers and ICBs, including measures of progress against reducing health inequalities, will not contribute to these scores, they will also be shown on this dashboard. An overall score will also be displayed for each provider indicating its position relative to organisations of the same type. Data related to segmentation will be updated quarterly.

In addition, once our approach to provider capability is finalised, we anticipate that the dashboard will include the provider capability ratings.

Segmentation response

Segmentation combined with consideration of NHS England’s assessment of provider capability will inform our oversight response.

Each NHS England region will co-ordinate the response to segmentation with NHS England national teams and wider system partners. We will use the segmentation scores alongside wider information to direct our oversight activities at those organisations that have lowest performance and lack the capability to improve without support.

We will base our oversight of performance improvement activities on essential principles that will be focused on the delivery of joint system plans. The frequency of review meetings with ICBs will depend on the confidence the region has in the ICB’s capability to deliver the required improvements. The system’s providers will be included in these meetings where required, for example where the ICB cannot drive the required improvement of a provider using the contractual levers it has with the provider. Further meetings to monitor in-year delivery and co-ordinate support will be scheduled as required.

We will align our improvement support offer to organisational delivery scores. For some priority areas for 2025/26 (reflected in the finance, urgent and emergency care, elective and mental health sub-domains), those providers with a relevant sub-domain score of 4 will receive the most intensive improvement support and this will be provided onsite. The offer for those with a sub-domain score of 3 will be predominantly offsite support. A universal improvement offer will be available to all organisations.

Where required, NHS England regional teams will undertake performance management activities (tiering) for providers with low performance in the priority areas of finance, urgent and emergency care, elective and mental health. In addition, a proportion will receive more intense scrutiny, and they may be supported by national programmes. Those organisations in segment 4 with an associated low provider capability may enter into the programme of support for our most challenged providers, the Provider Improvement Programme (PIP).

Table 3: Segment support needs

Emerging information and capability assessments

As part of NHS England’s assessment process, we will gather insights across the assessment domains. We will collect this mix of quantitative data and qualitative information annually, in-year or by exception.

Qualitative information may be derived from:

• ICBs and providers as part of routine interactions, for example around emerging financial risks or clinical quality risks in line with the National Quality Board guidance on risk response and escalation
• reports from other regulators such as the CQC, including ICS assessments and internal and external audit reports
• the police and coroner reports
• third-party information, for example whistleblowing, 360-degree feedback, peer reviews, complaints or formal publications/assessments

NHS England will work with regulators, including the CQC, Health and Care Professions Council, General Medical Council and Nursing and Midwifery Council, through the national and regional Joint Strategic Oversight Group. This group provides a space for regulators to share intelligence and develop aligned approaches to support organisations.

We will assess the information we gather as part of the separate provider capability assessment process; we will publish our approach for this in Q2 of 2025.

Critical to the assessment approach is the early identification of emerging issues and concerns, so they can be addressed before they have a material impact or performance deteriorates further. If necessary, this could include the use of NHS England’s enforcement powers in response to emerging information outside of the segmentation process. Issues and concerns may be identified outside the quarterly review of segmentation and may not relate directly to segmentation data. Organisations should not wait for the next cycle of the assessment process to acknowledge performance, finance or quality concerns. ICBs and providers should promptly escalate all issues that are significantly affecting performance, finance or quality to their NHS England regional team.

Oversight of delegated commissioning

NHS England remains accountable for those services it has delegated responsibility for the commissioning of to ICBs. These include certain specialised services and all primary care services (primary medical care, dentistry, pharmacy and ophthalmic services) and the handling of associated complaints. NHS England will hold ICBs to account for the performance of these services in their system through delegation agreements.

Oversight of delegated functions will form part of NHS England’s wider oversight of ICBs. In particular, NHS England will use the ICB annual assessment to judge whether delegated commissioning activities and associated complaints handling are being carried out appropriately. This may involve the in-year monitoring of additional data in relation to delegated services.

Incentives and consequences

NHS England is committed to supporting providers and ICBs to drive improvement and deliver high quality care for all. We want to see high-performing systems across the country and to embed earned autonomy and incentives into the operating framework. There has already been progress: fewer national priorities in the planning guidance increases local flexibility in decision-making.

NHS England will work closely with those providers that are high performing, as reflected by their segment and their leadership capability, to draw on their expertise in shaping and driving national policy and to test new models of care.

NHS England will also introduce greater performance incentives in 2025/26 and these will be reviewed for 2026/27 as we implement the 10 Year Health Plan. For example, to incentivise revenue performance, the 2025/26 capital planning guidance proposes that high-performing providers and ICBs that demonstrate effective governance, strong financial management and operational resilience will receive some freedoms and flexibility, including a partial release of revenue surpluses for capital expenditure. As set out in the Elective Reform Plan, we also intend to introduce capital incentives for improvements in elective performance.

Furthermore, to hold senior leaders to account for their performance in delivering high quality care and managing finances, in line with the NHS very senior managers pay framework, very senior managers of organisations in segment 5 (noting the ICBs in the RSP will be treated as such) will not be eligible for the annual pay award, unless exempt.

Enforcement

NHS England’s oversight of ICBs and providers may involve the use of our regulatory powers to take enforcement action, in line with the NHS enforcement guidance, against a provider if it has breached its licence or we suspect it has.

NHS England has a range of statutory powers to address serious issues at providers. While the NHS Oversight Framework is the operational tool through which NHS England will identify providers that require support or intervention, where our assessment and monitoring highlight serious concern with performance, quality or other areas and, after further enquiries or investigation, we are satisfied that the relevant statutory thresholds are met, we may use our enforcement powers to address the concern, according to the level of concern and in accordance with the NHS enforcement guidance. We do not expect to use of our enforcement powers for organisations in segment 1 as they do not have intervention or support needs. However, if necessary (for example, if a serious leadership or governance concern emerges), we can still take enforcement action for organisations in this segment and their segment may be reviewed.

Where providers fail to comply with their obligations under their provider licence (or are reasonably suspected of failing), NHS England may use powers including:

• Provider undertakings – can be used where NHS England has reasonable grounds to suspect that a provider has failed to meet the conditions of its NHS provider licence. We may agree to accept legally binding undertakings to secure progress where providers are capable of resolving performance issues themselves.
• Provider discretionary requirements – can be imposed to require the remedy of a breach of an NHS provider licence where NHS England is satisfied that a breach has occurred. We may consider imposing discretionary requirements based on a range of considerations to ensure that progress is made, including where we do not have confidence the provider is taking sufficient action to resolve performance issues.

NHS England has powers in relation to NHS trusts that we may use in appropriate cases to effect executive leadership change, and the power to remove chairs and non-executive directors. For NHS foundation trusts, NHS England can also impose additional licence conditions relating to governance, breach of which may then lead to leadership change.

NHS England may consider using our powers of direction or additional licence conditions in more serious cases of governance failure.

More information can be found in the NHS enforcement guidance, including how NHS England chooses which powers to use and when, the factors we consider when enacting them and how we ensure consistency in approach. 

Annex A: Delivery metrics

The assessment process measures each provider’s delivery across 6 domains, as set out in Table 1 of the framework. Each domain has a range of appropriate metrics for each type of organisation (ICB, acute, mental health, community and ambulance trusts); these are set out in the tables below. For this transitional year, the scoring metrics (in bold) reflect the 2025/26 NHS priorities and operational planning guidance. The other contextual metrics will not influence the segmentation score.

Table A1: Access domain metrics

These metrics relate to the national objectives set out in the 2025/26 NHS priorities and operational planning guidance and other commitments relating to the NHS Constitution. All metrics are scored (denoted in bold) other than 2 mental healthcare and 2 primary care contextual metrics which do not form part of the segment score.

Elective care

Cancer

Urgent and emergency care

Mental health care

Primary care

Table A2: Effectiveness and experience of care domain metrics

These metrics relate to the role of NHS bodies to continuously improve the quality of care patients receive. Most metrics are scored (bold), but some are non-scoring contextual metrics and therefore do not contribute to the overall domain and segment score.

Primary care

Table A3: Patient safety domain metrics

These metrics relate to how organisations ensure that patients are kept safe, a core element of high-quality care. Most are scored (bold), but some are non-scoring contextual metrics.

Primary care

Table A4: People and workforce domain metrics

These metrics relate to how NHS organisations ensure the wellbeing of those who provide and support care. These are a mix of scored (bold) and contextual metrics.

Primary care

Table A5: Finance and productivity domain metrics

These metrics will be used to judge individual organisational financial delivery. They all contribute to trust segmentation but are contextual for ICBs.

Finance

Productivity

Table A6: Improving health and reducing inequality domain metrics

These metrics relate to longer-term priorities aimed at improving population health and reducing inequalities. They are all non-scoring contextual metrics and therefore do not contribute to the overall domain and segment score.

Improving population health

Primary prevention

Inequalities

Table A7: System performance for ICBs

These metrics relate to tests applied at a whole system level for ICBs. They are contextual metrics and not applied in 2025/26.

Publication reference: PRN02028